Harassment, Intimidation Or Bullying - Targeted Student Safety Plan Template Page 3
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7.
Other: __________________________________________________________________
B. The Targeted Student:
1.
The student will not have face to face contact or online contact with the aggressor while
this plan is in effect.
2.
The school counselor and the student will identify a friend or friends with whom he/she
feels safe.
3.
The student will remain as close to the trusted friend(s) as is reasonable during the school
day.
4.
The student will visit the school counselor (nurse / principal / AP) on a daily basis at
________o’clock to check in to see that the plan is working.
5.
The student will share all passwords and will ‘friend’ his/her parents on all social networking
sites so that they can monitor for any adverse online experiences.
(NB: The student will not ‘friend’ teachers or other school staff.)
SAMPLE
6.
The student will report any breach of this plan to his/her parents, designated trusted adult,
teacher, or other staff person immediately
7.
The student will also report any such behavior which occurs as a result of this plan off
campus and/or outside of the regular school day.
8.
Other:
_______________________________________________________________________ .
Parents/Family:
1.
Parents and other family members agree to monitor and support the student with this
Safety Plan, monitor the student’s use of technologies, and contact school if the problem persists.
2. Parents are welcome to contact the school at any time to check on the effectiveness of the plan.
If threats and harassment continue and/or escalate, law enforcement may be called in.
This plan is in place from _____________________________ through __________________, at which
time it will be reviewed, revised or continued, if necessary.
We agree to the Safety Plan as stated above.
__________________________________________ ________________________________________
Student
Parent
__________________________________________ ________________________________________
Principal
Date
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